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Massa v. Saul

United States District Court, E.D. Missouri, Eastern Division

September 11, 2019

ROBIN J. MASSA, Plaintiff,
ANDREW M. SAUL, [1]Commissioner of Social Security, Defendant.



         This is an action under 42 U.S.C. § 405(g) for judicial review of the final decision of Defendant Andrew M. Saul, Commissioner of Social Security (the “Commissioner”) denying the application of Plaintiff Robin J. Massa (“Plaintiff”) for Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act, 42 U.S.C. §§ 401 et seq. (the “Act”). The parties consented to the jurisdiction of the undersigned magistrate judge pursuant to 28 U.S.C. § 636(c). (Doc. 8). Because I find the decision denying benefits was not supported by substantial evidence, I will reverse the Commissioner's denial of Plaintiff's application and remand the case for further proceedings.

         I. Procedural Background

         On March 16, 2015, Plaintiff applied for DIB, alleging that she had been unable to work since March 13, 2015. (Tr. 145-46). Her date last insured was September 30, 2015. (Tr. 16). Her application was initially denied. (Tr. 75-78). On August 25, 2015, Plaintiff filed a Request for Hearing by Administrative Law Judge (ALJ) (Tr. 82-83). On September 13, 2017, the ALJ issued an unfavorable decision. (Tr. 11-27). On October 2, 2017, Plaintiff filed a Request for Review of Hearing Decision with the Social Security Administration's Appeals Council. (Tr. 142). On May 1, 2018, the Appeals Council denied Plaintiff's request for review. (Tr. 1-3). The decision of the ALJ stands as the final decision of the Commissioner of the Social Security Administration.

         II. Factual Background

         At the outset, the Court notes that because Plaintiff's date last insured was September 30, 2015, she was required to show that she was disabled prior to that date. See Moore v. Astrue, 572 F.3d 520, 522 (8th Cir. 2009). Thus, as the ALJ did, the Court will focus primarily on the facts relevant to the period between her alleged onset date (March 13, 2015) and her date last insured (September 30, 2015). Additionally, because Plaintiff's challenges to the ALJ's decision focus on her physical impairments rather than her mental impairments, the Court will focus primarily on the evidence relevant to her physical impairments.

         On June 4, 2015, Plaintiff completed a Function Report in which she reported that she was unable to stand for more than ten minutes without back pain; that sitting too long hurt; that she could not lift things on a regular basis due to rib and back pain; and that she got shortness of breath walking up and down stairs or for long distances. (Tr. 199). She reported that she typically makes a cup of coffee, sits on a computer for about an hour, watches television, and tries to do some light housework, such as sweeping or dusting. She reported waking up several times a night and having difficulty falling asleep. (Tr. 200). She reported being able to drive for about an hour at a time. (Tr. 200). She prepared simple meals daily. (Tr. 201). She reported sweeping floors, dusting, and doing laundry, though her spouse carried the laundry up and down the stairs. (Tr. 201). She reported shopping in stores for groceries. (Tr. 202). She reported that she can no longer go to yard sales, because getting in and out of the car often hurts. (Tr. 206). She stated that she cannot hold her grandchild for longer than ten minutes if she is sitting down. (Tr. 206). She stated that her back and rib cage hurt constantly and that pain relievers do not really help. (Tr. 206). She also stated that due to her chronic fibromyalgia, she has not been able to do anything that she used to do; if she does anything extra, she cannot move very well the following day. (Tr. 206).

         On April 13, 2017, Plaintiff testified as follows at the hearing before the ALJ. Plaintiff testified that she gets short of breath when she does a lot of walking or goes up steps. (Tr. 41). Her lower back hurts all the way down into her left leg. (Tr. 41). She cannot sit for very long and cannot walk or stand for very long. (Tr. 41). She also has COPD (Tr. 41). Plaintiff has also been diagnosed with fibromyalgia, which causes her shoulders to ache and causes joint pain in her elbows, knees, and hips. (Tr. 42). Plaintiff has been depressed for several years and is on medication. (Tr. 41). Plaintiff testified that she has good days and bad days. (Tr. 42). On a bad day, she gets up, makes a little breakfast, and sits in her recliner off and on all day long. (Tr. 42). On a good day, she might go out into the backyard with her dogs or might drive to the Dollar Store. (Tr. 42). She testified that she has bad days about three or four days a week, which is an improvement over when she stopped working and the bad days were every day. (Tr. 44).

         Plaintiff stopped working in March 2015, because she could not do her job anymore. (Tr. 43). She had trouble carrying and filing legal briefs, and she had trouble walking up and down the steps to the basement to get the mail. (Tr. 43). She also could not sit for very long. (Tr. 43). She also had bouts of crying fits on the job. (Tr. 43). Her energy level was very low. (Tr. 44).

         Plaintiff's daughter also testified at the hearing before the ALJ. Plaintiff's daughter testified that before Plaintiff moved in with her, Plaintiff's daughter visited her three to five times a week to do “typically all of her housework, ” including laundry, sweeping, cleaning bathrooms, doing dishes, and yard work. (Tr. 47). Plaintiff was able to do some of those activities with her daughter, but it took her a long time because she could only stand for a little while. (Tr. 48). She seems to be okay if she is standing or walking for short periods of time, but she could not, for example, stand at the sink for half an hour to do dishes. (Tr. 48).

         Plaintiff's medical records show that in the months leading up to Plaintiff's alleged disability onset date, Plaintiff reported pain in her ribs and thoracic spine, for which she received various medications. (Tr. 249, 253-59, 279-84, 295-301, 322-25, 358-360). In January 2015, she also began reporting pain in her lumbar spine. (Tr. 279-84). A January 2015 X-ray of the lumbar spine showed normal alignment, no evident spondylosis, and no osseous abnormality. (Tr. 249). In February 2015, she also began reporting pain in her shoulder, neck, knee, hand, elbow, and ankle. (Tr. 295). A plan was made for physical therapy. (Tr. 301).

         After her alleged disability onset date, Plaintiff continued to have back pain, as well as respiratory issues. On March 17, 2015, Plaintiff called her doctor's office with questions about her medications, stating that she had been in quite a bit of pain recently. (Tr. 348). On April 27, 2015, Plaintiff presented to the emergency room with chest pain. (Tr. 376). On July 28, 2015, an MRI of the thoracic spine performed due to mid back pain showed no evidence of central canal or neuroforaminal stenosis throughout the thoracic spine; no evidence of disc bulge or herniation within the thoracic region; and “partial visualization of a disc bulge/HNP at the C5-6 level.” (Tr. 536). On August 20-21, 2015, a pulse oximetry summary report indicated that Plaintiff qualified for nocturnal oxygen under Medicare guidelines. (Tr. 515). On September 2, 2015, Plaintiff was diagnosed with chronic obstructive lung disease, benign essential hypertension, anxiety, and abnormal liver function, and smoking cessation was strongly recommended. (Tr. 400). On September 8, 2015, a lumbar spine X-ray showed mild degenerative changes of the lumbar spine (Tr. 644); a lumbar spine MRI showed degenerative changes of the lumbar spine resulting in mild spinal canal and mild-to-moderate neuroforaminal stenoses (Tr. 642-43); and a pelvic X-ray showed mild degenerative changes of the sacroiliac joints and the hips (Tr. 640). On September 24, 2015, Plaintiff filled out a physical therapy questionnaire indicating that pain medication provided her with little pain relief and that she had difficulty walking more than a quarter of a mile, sitting for an hour, or standing for more than a half an hour. (Tr. 548). Her “Oswestry Back Disability Index” showed a total disability score of 48%, though it was noted that the score was expected to decline over the course of treatment. (Tr. 547). A plan was made for physical therapy two to three times per week for four to six weeks. (Tr. 551). On September 29, 2015, Plaintiff returned to physical therapy, though she was unable to tolerate some exercises. (Tr. 556-57).

         In the months following Plaintiff's date last insured, she had steroid injections for lumbar pain (Tr. 678-79), and she went to the emergency room on several occasions for rib, chest, or abdominal pain or breathing problems (Tr. 495, 568-69, 575, 583). She also sought treatment for pulmonary issues and thoracic spine pain. (Tr. 620, 627, 395-98, 504-05).

         With respect to the other details Plaintiff's medical records and the other records in the administrative transcript, the Court adopts the facts as presented in the parties' respective statements of fact. The Court will cite to ...

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